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Pros and Cons of The Quality Initiative

Pros and Cons of The Quality Initiative. R H Haralson III, MD, MBA haralson@aaos.org. Problem 1 QUALITY. The quality of medical care IOM study – “To Err is Human” 50% of treatment we render is inappropriate (Elizabeth McGlynn) The older the physician the worse it is

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Pros and Cons of The Quality Initiative

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  1. Pros and Cons of The Quality Initiative R H Haralson III, MD, MBA haralson@aaos.org

  2. Problem 1QUALITY • The quality of medical care • IOM study – “To Err is Human” • 50% of treatment we render is inappropriate • (Elizabeth McGlynn) • The older the physician the worse it is • Cost and quality have an inverse relationship North Carolina Medical Society 2008

  3. Orthopaedics • Fractured hips (9 parameters) • Prophylactic antibiotics • Prophylactic thromboembolism medications • Proper lab work • Coagulation profile North Carolina Medical Society 2008

  4. Orthopaedics Received appropriate regimen 22% North Carolina Medical Society 2008

  5. Problem 2COST The cost of medical care • To build a car, it costs more for medical insurance than metal • The cost of medical insurance is more than a minimum wage earner’s annual salary • 16% of the GNP • It is un-stainable North Carolina Medical Society 2008

  6. North Carolina Medical Society 2008

  7. North Carolina Medical Society 2008

  8. Alphabet Soup of the Quality Initiative • PCPI – AMA Physician's Consortium for Performance Improvement • NCQA – National Committee for Quality Assurance (HEDIS and Managed Care) • NQF – National Quality Forum • AQA – Ambulatory Quality Alliance (AHRQ) • HQA – Hospital Quality Alliance • SQA – Surgical Quality Alliance North Carolina Medical Society 2008

  9. Pros • Theoretical • Increase Quality (Safe, Timely, Efficient, Effective, Equal, Patient Centered) • Decrease costs • Quality is cheaper • Practical • If we don’t do it, it will be done for (to) us North Carolina Medical Society 2008

  10. Pros • Reduced practice variations • Catalyzes investment in HIT • Incentives for preventative care • Incentives for health plan competition North Carolina Medical Society 2008

  11. Cons Process vs. Outcomes • We want outcomes • Process can be a surrogate for outcomes (audit) • Outcomes point out a problem but does not identify the source North Carolina Medical Society 2008

  12. Cons No good way to risk adjust • Especially in surgery • Co-morbidities • Patient non-compliance • Cultural and religious differences • Statins example North Carolina Medical Society 2008

  13. Cons Attribution • Care provided by multiple providers • Fractured hip with cardiovascular disease • Fractured hip with osteoporosis • Assigning measures to a specialty North Carolina Medical Society 2008

  14. Rebuttal With large population studies, risk adjustment and attribution are not necessary North Carolina Medical Society 2008

  15. Cons • No good surgical measures • Need to be under the control of the surgeon • Infection rate • Better for chronic conditions (Diabetes, Heart Disease and Asthma) North Carolina Medical Society 2008

  16. Cons Increase efficiency and conservatism results in decreased revenue • Payment system must be revised • (Part A and Part B) • Need to pay more for conservative treatments • The fact that P4P programs are added on top of existing fee for service programs leads to conflicting incentives North Carolina Medical Society 2008

  17. Cons • Unintended consequences • Measuring Hgb A1c in diabetics • Did the doc do anything about it • Examination of the retina • Control of hypertension is much more important North Carolina Medical Society 2008

  18. Cons • Incentives • 1% - 2% too low • 10% about right but that may lead to increased costs • The incentive must be greater than the incentive to produce • Where does the money come from North Carolina Medical Society 2008

  19. Cons • Do you reward improvement or maintenance • The terrible get better (tier 4 to tier 3) • The best cannot get better • Some think recognition is enough • What about punishment of those that do not meet the benchmarks (Tournament approach vs. rewarding anybody) North Carolina Medical Society 2008

  20. Cons Effeciency measures Cost / quality = Efficiency Cost = episodes of care (groupers) Cost (bad number) / Quality (bad number) = Nirvana (efficiency) North Carolina Medical Society 2008

  21. Cons • Errors in reporting • Wash. U. experience • Black boxes • Transparency • Lack of appeal mechanism North Carolina Medical Society 2008

  22. Cons • Burden of collecting data • Databases are wonderful but somebody has to enter the data • Payers want available data • Chart abstraction • EMR will eventually be necessary • Voice recognition • Point and click (Structured Data) North Carolina Medical Society 2008

  23. Cons • So far the data demonstrating success of P4P is sparse. • Some success but moderate • Problems with low financial incentives • P 4 Performance vs. P 4 Reporting • Low hanging fruit North Carolina Medical Society 2008

  24. North Carolina Medical Society 2008

  25. North Carolina Medical Society 2008

  26. Theoretical Con • Med Students and interns are taught to think sequentially or longitudinally • Emergencies require thinking and acting at the same time • Physicians need both • EBM leans toward sequential thinking • Read “Blink” and “How Doctors Think” North Carolina Medical Society 2008

  27. Theoretical Con • “Rare things don’t happen very often, but they do occur” • Harold Boyd, MD • You must not forget to look for Zebras North Carolina Medical Society 2008

  28. PQRI, 2008 • Voluntary • All of 2008 • Incentives are the same (1 ½%) (sort of) North Carolina Medical Society 2008

  29. PQRI, 2008 • Must report 3 measures on 80% of your eligible patients for the full year • 1 ½% bonus (Calculated on all your Medicare billings) • Tracked by Unique Identifier (NPI) • https://nppes.cms.hhs.gov/NPPES/ • Paid by pay number North Carolina Medical Society 2008

  30. Surgical Measures • Prophylactic antibiotics within 1 hour of surgery • Use of a first or second generation cephaolsporin • Discontinue antibiotics within 24 hours • Thromboembolic prophylaxis North Carolina Medical Society 2008

  31. 10 Orthopaedic Measures • Communication with PCP • Screening for future Fall Risk • Screening for Osteoporosis • Management following fracture (DEXA) • Pharmacological Therapy • Counseling on use of vitamin D and exercise North Carolina Medical Society 2008

  32. 4 New Measures • Adoption of Health IT • Adoption of E-prescribing • Diabetic vascular exam • Diabetic foot ulcer exam North Carolina Medical Society 2008

  33. Other Possibilities • Medication reconciliation • Disease modifying anti-rheumatic drug therapy in rheumatoid arthritis • Inquiry regarding tobacco use • Advising smokers to quit. North Carolina Medical Society 2008

  34. How Do I Report? • CPT Level II code on the CMS 1500 form along with your procedure/management code (4047F) • Modifier • 1P I did not do it for a reason • 8P I did not do it for no reason North Carolina Medical Society 2008

  35. AAOS PQRI WORKSHEET • Measure #20: Perioperative Care: Timing of Antibiotic • Prophylaxis–Ordering Physician CPT II 4047F, 4048F, • Modifier 1P: • SURGICAL PROCEDURECPT CODE • Spine 22325, 22612, 22630, 22800, 22802, 22804, 63030, 63042 • Hip Reconstruction 27125, 27130, 27132, 27134, 27137, 27138 • Trauma (Fractures)27235, 27236, 27244, 27245, 27758, 27759, 27766, 27792, 27814 • Knee Reconstruction 27440-27443, 27445-27447 • Neurological Surgery 22524, 22554, 22558, 22600, 22612, 22630, 35301, 63015, 63020, 63030, 63042, 63045, 63047, 63056, 63075, 63081, 63267, 63276 North Carolina Medical Society 2008

  36. Resources www.cms.hhs.gov/pqri www.aaos.org/pqri Articles Webinar Worksheets Step by step instructions North Carolina Medical Society 2008

  37. Latest Concepts Care Coordination Communication among all care givers, caring for a patient, in an effort to fully inform all caregivers of the necessary medical information to achieve continuous, safe, timely, effective, efficient, equitable and patient centered medial care. North Carolina Medical Society 2008

  38. Care Coordination Medical Home Does not have to be a PC North Carolina Medical Society 2008

  39. Latest Concepts Composite Measures Combination of several measures like McGlynn North Carolina Medical Society 2008

  40. Summary • Pros - short list (quality and cost) • Rewards are possibly great • Consequences of not doing it are disastrous North Carolina Medical Society 2008

  41. Summary • Cons - Long list with lots of problems • All are remedial • Eventually it will look different • We will always have to prove quality • What will really help is when we measure the insurance companies North Carolina Medical Society 2008

  42. Prediction 1. Quality reporting is here to stay 2. Eventually it will not be “P4P”, it will be “Report to Survive” North Carolina Medical Society 2008

  43. Admonishment “If we do not make this quality movement work, it will all be on cost.” Susan Nedza, MD Chief Medical Office , CMS, Now VP AMA North Carolina Medical Society 2008

  44. Thank You North Carolina Medical Society 2008

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